Mattress Exchange Form
Location:
 Sales Person:
 Original Sale Date:
Original Sale #:
Customers:
Name:
 Current:
Address:
 City:
 State:
 Zip:
If damaged please describe the
 damage in the box to the right.
 Example: Customer has 2 1/2
inch body impression.
Warranty Exchange:
Yes
Damaged?:
Comfort Exchange:
No
Very Bad
 Poor
 Average
 Good
 Great
Please Rank Mattress Condition. 1-5 Scale:
1
 2
 3
 4
 5
Yes
 Yes
 Yes
 Yes
Is Label:
Attached?:
 Law Tag:
Attached?:
 Mattress:
Stained?:
 Does the Customer Have:
Proper Center Supports?:
No
 No
 No
 No
Mattress Inspection Was Done By:
 Sales Person (Myself)   |
 Customer   |
 Simmons Representative
Desired Exchange Date:
Exchange Mattress Only:
 Exchange Complete Set:
Mattress To Be Picked Up:
(mattress name)
 Mattress To Be Delivered:
(mattress name)
Twin
 Full
 Queen
 King
 Twin XL
 Twin
 Full
 Queen
 King
 Twin XL
Size Of Mattress:
To Be Picked Up:
 Size Of Mattress:
To Be Delivered:
:Before Tax
 :Total With Tax
Apply Up Charge
 Apply Refund
 Even Exchange
Apply Delivery Fee and Deliver
 Deliver Free of Charge
 Exchange At Store
 Exchange At DC
Debit or Credit:
Customer via:
 Special Instruction Box: